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Final Medicare Drug Plan Regs May Frustrate Some Patients

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Officials at the Centers for Medicare and Medicaid Services (CMS) have completed work on Medicare drug coverage regulations that could give the plans help with holding down drug prices.

CMS — an arm of the U.S. Department of Health and Human Services — will apply the new regulations to Medicare Part D drug plans, and to Medicare Advantage plan drug benefits.

(Related: CMS Proposes Medicare Part D Update)

Some provisions in the final regulations are supposed to give consumers more information about what drugs cost and affect how drug manufacturer rebates work.

For producers in the Medicare plan market, the provisions that may lead to the most conversations with clients might be the formulary cost management provisions.

A formulary is a list of the drugs a plan will cover.

In the past, CMS has required a Medicare drug plan formulary, or covered drug list, to include most of the available drugs in six major drug categories: antidepressants, antipsychotics, anticonvulsants, antiretrovirals, anticancer drugs, and immune system suppression drugs for transplant patients.

Now, a plan can restrict access to drugs in those categories in some cases, by, for example, letting a drug plan require many patients to try a cheaper drug before moving up to a more expensive drug. Requiring a patient to try a cheaper drug first is called “step therapy.”

In the commercial plan market, patients and providers have often resisted step therapy requirements.

To ease patient concerns about the new step therapy rules, CMS says it will speed up its process for handling patient appeals related to the kinds of drugs affected by the new rules.


A preliminary version of the final Medicare Part D and Medicare Advantage drug price regulations is available here.

— Read Drugmakers Will Have to Put Prices in Ads: Feds, on ThinkAdvisor.

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